American Academy of Orthopaedic Surgeons approves clinical practice guidelines and appropriate use criteria related to combat and civilian patient trauma

ROSEMONT, Ill. (December 12, 2019) — The American Academy of Orthopaedic Surgeons (AAOS) released a series of new Clinical Practice Guidelines (CPG) and Appropriate Use Criteria (AUC) to help physicians who treat combat and civilian trauma patients. The new materials are intended to offer guidance on diagnosis and management decisions for adult patients with severe extremity trauma. Each was created as part of a joint effort between a volunteer workgroup of musculoskeletal trauma surgery experts, military surgeons and AAOS research staff—part of the Major Extremity Trauma and Rehabilitation Consortium.

“The development of new CPGs and AUCs stem from the first-ever grant awarded to the AAOS from the U.S. Department of Defense,” explained Kevin G. Shea, MD, chair of the AAOS Committee on Evidence-Based Quality and Value. “The trauma-related injury topics identified through the grant were areas in which significant variation in orthopaedic emergent care existed. We sought to provide physicians with a measure of when, how and for whom medical and surgical procedures should be used when dealing with traumatic extremity injuries to better optimize patient care – whether civilian traumatic events such as motor vehicle accidents or military scenarios.”

Highlights of the treatment tools include:

• CPG for limb salvage or early amputation – This CPG specifies the factors that should weigh heavily on an initial decision to amputate (survival of the patient and resuscitative efforts), and findings that should inform subsequent discussion with the patient, but not necessitate an acute amputation (vascular or nerve status, injury scores and smoking status). It also defines the important criteria that may make lower-extremity limb salvage more or less advisable in the short term. These characteristics will help physicians to have an informed and data-driven conversation with patients as to the eventual expectations of function and potential complications with either treatment pathway.
• AUC for limb salvage or early amputation – The AUC online tool provides clinicians algorithms on how to optimally treat the injury or condition, including hypothetical scenarios and possible treatments, ranked for appropriateness based on the latest research, clinical expertise and experience. The limb salvage AUC offers seven indication profiles covering lower-extremity injury variables including the limb site (leg, foot/ankle, or both), type and severity of injury, presence and degree of contamination, and comorbidities. When these parameters are selected, a recommendation in regard to salvage or amputation is provided.
• CPG for evaluation of psychosocial factors influencing recovery from adult orthopaedic trauma – Based on a formal systematic review of published studies, this CPG addresses psychosocial factors influencing clinical, functional and quality of life recovery following military and civilian adult orthopaedic trauma. It recommends that clinicians shift toward a holistic, interdisciplinary approach evaluating the following factors: anxiety, PTSD, depression, premorbid psychiatric conditions, smoking, lower education level, social support and resilience issues.
• AUC for the diagnosis and management of ACS (released September 2019) – ACS is a potentially devastating complication that can occur after a severe injury to a limb, such as in a motor vehicle collision. Swelling or bleeding may occur within a limb compartment containing muscles, nerves, and blood vessels. Because disrupting the flow of blood, oxygen and nutrients to the arms, legs, hands, feet and buttocks can damage nerve and muscle cells and cause permanent disability and tissue death, prompt and accurate diagnosis is critical. This resource provides clinicians with an algorithm-style tool for choosing management pathways based on the patient’s presenting indications, as entered by the physician. The treatment scenarios provided by AUC stem from recommendations in CPGs issued by the AAOS in December 2018.

“This collaboration was a fruitful example of many stakeholders in musculoskeletal healthcare working together to achieve a common goal,” added Benjamin J. Miller, MD, FAAOS, with the University of Iowa’s Department of Orthopaedics and Rehabilitation. “The assembled work group not only informed the discussion with many different perspectives on patient management, but also represented a comprehensive cross section of the important musculoskeletal issues and goals in the care of patients with traumatic extremity injuries.”

Approximately 2 million individuals in the United States are living with limb loss, with nearly one half of those due to trauma and a substantial majority of trauma-related amputations involving the lower extremity[i]. CPGs and AUCs recommend accepted approaches to treatment and/or diagnosis of these types of injuries and are not intended to be a fixed protocol. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances. Practitioners are advised to consider management options in the context of their own training and background and institutional capabilities.

The full CPGs and AUCs are intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app.

More information on the development process for AAOS clinical practice guidelines, is available online: Clinical Practice Guideline Methodology.

About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

About METRC
METRC is a nonprofit collaborative effort of 22 civilian centers and four military treatment facilities dedicated to helping establish treatment guidelines for the optimal care of military traumatic injuries.

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[i] Ziegler-Graham et al Archives of Physical Medicine and Rehabilitation 2008.